Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities


Journal Article

© 2018, The Author(s) 2018. Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Full Text

Duke Authors

Cited Authors

  • Toles, M; Leeman, J; Colón-Emeric, C; Hanson, LC

Published Date

  • June 1, 2018

Published In

Electronic International Standard Serial Number (EISSN)

  • 1552-4523

International Standard Serial Number (ISSN)

  • 0733-4648

Digital Object Identifier (DOI)

  • 10.1177/0733464818783689

Citation Source

  • Scopus